ComEd customers facing or recovering from an electric shutoff use this one-page certificate to stop disconnection for 60 days while they set up a payment arrangement. Clinicians meet it when someone in the household has a medical condition that losing service would aggravate. Under 83 Ill. Adm. Code 280.160 it can be used once in 12 months, unless the balance tied to the last certificate has been paid off.
The customer fills in the account number, name, contact number, service address and the name of the ill resident. A licensed physician, physician assistant or licensed practitioner completes and signs the lower section; a local Board of Health can also issue a medical certificate.
The opening paragraph explains that a certificate from a doctor or local Board of Health can temporarily stop disconnection for 60 days, once in 12 months unless the prior certificate's balance was paid. It lists what the certificate must contain: account number, service address and contact number, the resident's name, a statement about aggravating or creating a medical emergency, and the certifier's contact details.
A short note to the clinician says that all requested information on the form must be completed for the medical certification to be valid. It also states that certification is only accepted from a licensed physician, physician assistant or licensed practitioner, so staff without one of those licenses should not sign.
The customer enters the ComEd account number, customer name, best contact number, service address with city, state and ZIP, and the name of the ill person residing at the address. The person named here is the patient the practitioner certifies, and they must live at the service address.
Select your title (physician, physician's assistant or licensed practitioner), then enter your name, office phone number and office address with city, state and ZIP. ComEd's checklist requires the name and contact information of the doctor or Board of Health, so these fields cannot be left blank.
The statement reads that in your professional opinion the patient has a medical condition that would be aggravated by the absence of energy service. No diagnosis or code is requested. Sign and date on the line for the physician, physician assistant or licensed practitioner.
The bottom of the form tells the signer to fax the signed form to ComEd or upload it at ComEd.com/submitform. Once ComEd receives it, a representative contacts the customer to complete the payment arrangement. ComEd's instructions also require the customer to contact ComEd within 14 days after a service interruption.
Download the current version from the source each time; forms change without notice.
Request for Medical Certification
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
Sources for this guide
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ComEd accepts certification only from a licensed physician, physician assistant or licensed practitioner, who selects their title on the form. A local Board of Health can also provide a medical certificate. The signer gives their name, office phone and office address, then signs and dates the statement.
A valid certificate stops disconnection for 60 days. It can be used if the customer has not used a medical certificate in the past 12 months, or has paid off the unpaid balance related to the last one. During that time a ComEd representative contacts the customer to set up a payment arrangement.
No. The practitioner certifies that, in their professional opinion, the patient has a medical condition that would be aggravated by the absence of energy service. ComEd's checklist asks for a statement that disconnection would aggravate an existing medical emergency or create one, plus the practitioner's contact details, not a named condition.
Yes. ComEd posts a Spanish version titled Solicitud de Certificado Medico. Its introduction and requirements are in Spanish, while the customer and practitioner field labels remain in English, so the practitioner section reads the same on both versions.